be treated later in the report, are those which provide personal services as distinguished from skilled nursing services.

Skilled nursing care available as an “adjunct" service in a home primarily for boarding and personal care would theoretically not qualify an establishment as a nursing home under these definitions. In actual practice, however, it was discovered that the prevalent looser type of interpretations exercised considerable sway over the classifications made of individual homes in the field. The end result, it must be recognized, is that the facilities classified as nursing homes in the study actually represent a combination of homes which provide skilled nursing care as their primary function and of homes which give a measure of skilled nursing care only incidentally to their prime function of personal care.

In two study States, New York and Wyoming, this combination can be subdivided clearly into the two component groups. How the two subgroups vary in these States in the types of patients and care found in the respective homes are examined in the next section (see pages 25-27).

Survey Procedures

The model survey plan which was developed out of the pilot study in Maryland was furnished in guide form, together with personal consultation, to the States which joined in the overall study. Carrying out the survey under the basic plan was the responsibility of the sponsoring agency in the State (see list on p. iv).

The general survey pattern involved a visit to the nursing home by a field agent, usually a nurse, who, with the assistance of the nursing home administrator and other staff members, completed a schedule of information on each patient in the home on that day. Patient records maintained in the nursing home were used as needed and available. Alternative methods allowed for completion of the schedules by the nursing home staff themselves. In any event, it should be recognized that a basic limitation of the survey data is that these data cannot go beyond what the nursing home administrator and his staff know and report about each patient.

Information gathered on the patients included personal data, date of admission to the nursing home, diagnoses as available, nature and extent of disability, nursing and personal services received, physician's care, charges, and source of funds for payment. Certain information about the homes themselves was obtained, including the length of time they had been in operation and the number and types of staff employed. (The physical characteristics of the homes, often studied in the course of inspections under licensing programs, were not covered in this study.)

Each State did its own field work, processed its own schedules and tabulated the results, using the uniform procedures, classifications, codes, and tabulations outlined in the standard guide. This guide has been published in essentially the form followed in the study (8).

With the continuing cooperation and participation of the responsible agencies in the 13 participating States, the Commission on Chronic Illness and the Public Health Service jointly processed and consolidated the survey findings, using a standard set of tables furnished by each State.

Time of Survey

The States joined the study at various periods during 1953 and 1954. The field data were gathered during those 2 years.

The time consumed in processing the schedules and machine tabulating the results varied among the States. The last of the State findings became available at the end of 1955, and consolidation of the data was completed during 1956.

Nursing Homes in the Nation

Stocktaking of existing nursing homes and related long-term facilities would assume more meaning if we knew the number of such homes in the country and the number of people they accommodate. Absence of reliable national figures on these elemental points was a major gap in information which hampered the Commission on Chronic Illness in its investigations. Because the Division of Hospital and Medical Facilities of the

Public Health Service was similarly hampered for lack of such information, this division conducted a national inventory of nursing homes and related facilities in 1954.

Reports (9-12) have been published which present in considerable detail the background, methods, and findings of that national inventory. Some of the resulting basic information is reviewed here as a helpful setting for the present analysis.

The National Inventory

The variety of facilities covered by the national inventory represented essentially all types of nonhospital facilities providing nursing or supportive services to chronically ill, convalescing, aged, disabled, or infirm persons. Specifically, it included nursing or convalescent homes, homes for the aged, boarding care homes for aged persons, public homes, children's convalescent homes, and special nursing homes for alcoholics, drug addicts, or mentally disturbed patients. Maternity homes and domiciliary facilities for children were excluded, as well as institutions for the blind and the deaf and institutions for the mentally deficient if they did not meet the study's definition of a nursing home by giving primarily "skilled nursing care."

The States and Territories submitted the survey data during the period April-October 1954. New field surveys were not requested for purposes of the inventory. Instead, the State agencies administering the Hill-Burton Hospital Survey and Construction Program were asked to furnish data on existing establishments, utilizing information already available to them or to other agencies and organizations or which was readily obtainable through such sources. The findings, therefore, lack some degree of accuracy and completeness. They are considered, however, to have sufficient scope and reliability to meet the current pressing needs for information.

The difficulties experienced with classification of homes in the patient study already described were analyzed carefully in developing the classification scheme of the inventory. The groupings of homes which came out of the patient study were essentially

those conventionally regarded as "types"— in effect the patient study took familiarly known types of homes and proceeded to observe their actual character as revealed through information about their residents.

The national inventory, in contrast, broke more sharply with conventional labels and established a classification structured more rigorously on rationale. It was built on the same basic definitions as were used in the patient study for "skilled nursing care" and "personal care" (see "Method and Scope of the Study"). In addition, it defined a third level of care: "shelter," representing room and board, minimum services of a custodial nature such as laundry, and personal courtesies such as occasional help with correspondence or shopping and an occasional helping hand short of the routine "personal care" defined earlier. Then, without regard to popular ways of designating homes-for example, nursing home, home for the aged, public home, boarding care home, and so on the inventory classified facilities into four categories, based on the predominant level of care furnished: skilled nursing homes, personal care homes with some skilled nursing, personal care homes without skilled nursing, and sheltered homes.

Findings of the National Inventory

The national inventory revealed a total of about 25,000 homes with approximately 450,000 beds. These facilities range from the boarding home for aged persons, which gives only the simplest supportive services, to the professional type of nursing home providing highly skilled and intensive nursing care.

Table 2 shows the number of facilities in the different categories of the inventory classification. Skilled nursing homes account for 40 percent of the total beds of all types reported.

Most of the homes in each of the types of facilities are under proprietary auspices (fig. 2). However, because voluntary and public homes are typically larger than commercial homes, they provide more of the total nursing home beds than might be expected (table 1, appendix B). In the case of skilled nursing homes, 9 out of every 10 are

to classify as proprietary nursing homes not only the type of facility which in the later terms of the national inventory was designated as "skilled nursing homes," but also the type identified in the inventory as "personal care homes with skilled nursing." In other words, in the patient study, most of the States did not distinguish between homes which provide skilled nursing care as their primary service and homes which function primarily for personal care but have some minor extent of skilled nursing services.

The basic definitions and classifications of the national inventory and the patient study had, to be sure, a close tie-in. However, in the patient study, the force of local custom and understanding often overrode the intended classification of homes. The definitions employed in the patient study narrowed the range of interpretation of the term "nursing home" but did not eliminate it.

The national inventory sought to draw sharper distinctions and to make clearer, more objective provision for categorizing homes into successive levels of skill. As a

total.

are in the United States an estimated 160,000 beds in 9,000 homes of the type construed in this study as proprietary nursing homes. As table 3 shows, the 13 study States reported 2,715 such homes with 39,179 patients. The study States achieved nearly complete coverage in the survey except that California and New York employed a planned sample.

The information presented in this section is based on actual reports for 1,686 proprietary nursing homes with 23,242 patients. The samples employed in California and New York will be expanded to represent the totals for those States so that they will carry their proper weight in the 13-State summation. The resulting 13-State totals which I will be cited in the analysis will therefore be 2,686 homes with 46,614 beds and 38,557 patients.

Personal Characteristics of Patients

Personal data gathered for the patients include age, sex, marital status, and race. The detailed findings by State are shown in table 2, appendix B.

Age

Nursing homes take their prime character from the age of their patients. The average patient is 80 years old.

Less than one-tenth of the patients in proprietary nursing homes are under 65 years of age (table 4). Very few indeed-little more than 1 percent of the total are less than 45 years old.

Figure 3 emphasizes how extreme is the age characteristic. As many as one-fourth of the patients are 85 years of age or older.

The chart also depicts the striking similarity in the age of patients among the survey